- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.65 / $40.50 / $45.69
| Professional | | $33.65 | $40.50 | $45.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.93 / $147.15 / $174.20
| Facility | | $108.93 | $147.15 | $174.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.86 / $43.38 / $69.68
| Professional | | $36.86 | $43.38 | $69.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.72 / $36.72 / $44.56
| Facility | | $36.72 | $36.72 | $44.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.81 / $36.72 / $36.72
| Professional | | $26.81 | $36.72 | $36.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.10 / $38.44 / $64.06
| Professional | | $30.10 | $38.44 | $64.06 |